Insomnia in Older Adults, Part II: Treatment
Amit Morris, BSc, School of Medicine, Queen’s University, Kingston, ON; Department of Psychiatry, Sleep and Alertness Clinic, Toronto Western Hospital, University of Toronto, Toronto, ON.
Henry J. Moller, MD, FRCP(C), DABSM, Department of Psychiatry, Sleep and Alertness Clinic, Toronto Western Hospital, University of Toronto, Toronto, ON.
Colin M. Shapiro, MBBCh, PhD, FRCP(C), Department of Psychiatry, Sleep and Alertness Clinic, Toronto Western Hospital, University of Toronto, Toronto, ON.
Chronic insomnia is common among older adults and has significant negative consequences for health and well being. A comprehensive approach to treatment begins with identification and management of any underlying conditions. Treatment of insomnia includes both non-pharmacologic and pharmacologic options. Non-pharmacologic approaches form the foundation of treatment; hypnotic medications can also be effective but may be associated with adverse drug effects. Zopiclone and zaleplon appear to be associated with fewer side effects than benzodiazepines.
Key words: insomnia, older adults, drug therapy, behavioural therapy, hypnotics.
Introduction
Insomnia—defined as difficulty falling asleep or staying asleep, or unrestorative sleep—is very common among older adults and is associated with significant negative effects on health, as well as decreased quality and length of life (see previous article in this series).1 Recent evidence suggests that this may be a consequence of loss of neurons in the ventrolateral preoptic nucleus.2 In animals, lesions in this area lead to more frequent but shorter bouts of sleep—resulting in a reduction in overall sleep time—as well as poorer sleep quality. This is similar to the sleep pattern of many older adults.
Because medical and psychiatric disorders as well as drug side effects are frequent causes of sleep problems in older adults, a thorough assessment is essential. The first step in treatment is to address any such underlying conditions. Numerous drugs can induce insomnia (see previous article in this series);1 changing medication or the time of administration may alleviate the problem. Alternatively, insomnia may be a primary disorder, without another condition or substance as its apparent cause. While an occasional disrupted night is normal, ongoing sleep difficulties—especially if they occur more than a couple of nights per week—merit intervention. The aim of intervention is to achieve both a treatment benefit (with an impact on quality of life) and a preventative effect (e.g., decreasing the subsequent chance of a depressive episode).
The previous article in this series discussed the prevalence and etiology of insomnia among older adults and provided an approach to its evaluation in a primary care setting.1 This article will review both pharmacologic and non-pharmacologic treatment options.
Pharmacologic vs. Non-Pharmacologic Treatment
Non-pharmacologic therapies form the foundation of treatment for chronic insomnia, especially in older adults. A non-pharmacologic approach is not associated with the risks of drug therapy, such as tolerance, dependence, “hangover” effects, substance-induced changes in sleep architecture, and medication interactions. Complications of drug therapy are both more likely and more problematic in older adults due to age-related changes in pharmacokinetics and pharmacodynamics, as well as comorbidities, polypharmacy, and increased susceptibility to falls and fractures. Non-drug therapies are often effective3 and can produce lasting improvements in sleep.4 Indeed, gains due to non-pharmacologic therapy may be better maintained than those achieved with the use of hypnotics.4
Newer non-benzodiazepine hypnotics (e.g., zopiclone, zaleplon) have better side effect profiles than benzodiazepines (BZs) and have improved the options for pharmacologic management. However, they—like BZs—are typically still recommended for short-term use only.5,6 Our view is that long-term therapy is warranted in some patients, given the negative effects of chronic sleep problems (see below).
Non-Pharmacologic Therapy
A number of non-pharmacologic insomnia treatments have been developed; these can be combined with each